Surgery Flashcards
What is the typical presentation of acute appendicitis? (4)
Abdo pain
Reduced appetite
Poss vom
Low-grade fever
Describe 3 features about abdo pain in acute appendicitis?
Central → RIF (less localised in younger)
Aggravated by moving (e.g. jump, cough, speed bumps)
Tenderness/guarding at McBurney’s
What are some features of an atypical presentation of acute appendicitis? (2) which may seem like other DDx
Diarrhoea + RIF pain (Gastroenteritis)
Abnormal urine dip (UTI)
What are some features of a late presentation of acute appendicitis? (2)
Abscess/palpable mass
Perforation
What is meckel’s diverticulum + what is its incidence in the general population?
What conditions may it lead to? (4)
How is it treated?
Ileal remnant of vitello-intestinal duct (gastric+panc)
2% all people
→ intussusception / volvulus (obstruction)
→ diverticulitis (abdo pain mimicks appendicitis)
→ lower GI bleeding
Tx: surgical resection
What is intussusception + what age group does it occur in?
Part of bowel invaginating into distal
B/wn 3m-2yrs
How does intussusception present? (3)
What are some late signs? (4)
Sudden episodes
Colicky pain
Abdo mass
Bloody/mucus (redcurrant jelly) stool (late sign)
Lethargy
Hypotonia
Shock
How is intussusception treated? (2)
Rectal air insufflation
If fails → surgery
What causes malrotation?
What is the commonest form/ what condition occurs as a consequence
How does malrotation present? (3)
How treated
Unfixed mesentery (duodenojejunal / ileocaecal) = shorter mesenteric base Caecal fixation to high posterior wall → Ladd bands cross duodenum (Obstruction) + Volvulus
Presents: Abdo pain, Bilious vomiting, Obstruction
Tx: urgent surgical correction
What is pyloric stenosis
What are the RFs ? (3)
What are the features/presentation? (5)
Pylorus hypertrophy → gastric outlet obstruction
RFs: Male (4:1), 1st born, FH (esp maternal)
2-7wks (regardless gestation)
Projectile + progressively frequent VOMITING
Hunger after vom → dehydration → lost interest (Wt loss if delayed)
Visible gastric peristalsis
What Ix are done for pyloric stenosis?
How is it managed? (2)
Test feed (palpable abdo mass + vom)
USS
U&Es (hyponat/kal/chlor)
Immediate fluid resuscitation (saline/gluc/K+)
Pyloromyomotomy (preserves mucosa)
What would be seen on AXR in duodenal atresia?
Double bubble + absence of air distally
How does an inguinal hernia occur?
What are the RFs (2) / incidence
Incomplete obliteration of processus vaginalis
Boys/ Premature (1 in 50 boys)
What situations would indicate more urgent surgery for inguinal hernia? (2)
Firm/tender/irreducible
Infant irritable/vomiting (risk strangulation/testes damage) (but delay 48hrs allowing oedema to resolve)
How does a hydrocele occur?
How does it present (5)
How managed?
Patent processus vaginalis (not wide enough for inguinal hernia but enough for peritoneal fluid to pass)
Present at birth /early childhood (post-viral/GI illness)
Asymp (usually bilateral) scrotal swelling
Transilluminable
Non-tender
Bluish discolouration
What is a varicocele?
How does it present? (2)
What are the complications? (2)
Varicosities of testicular vv’s
Usually L sided
Drag/ache/asymp
Risk impaired testicular growth / infertility
What is the incidence of undescended testis (cryptochordism) in term babies? + by 3m old?
What Ix (other than clinical Ex) can be done? (3)
4% term babies
1.5% by 3m
USS (obese boys)
Testosterone levels (HCG stimulated) (if suspect absent)
Laparoscopy
What conditions (2) may appear to have a ‘missing’ testicle later in life? (school/adolescence)
Retractile Ascending (relative shortening of cord during growth)
What 2 possible operations are done in undescended testis?
Orchidoplexy (mobilised + preserves vas)
Orchidectomy (for intra-abdo testis in older)
What complications may occur if an undescended testicle is not operated on? (3)
Sub/Infertility (plexy by 2y/o = normal; bilateral plexy = 50%)
Malignancy (histologically abn)
Cosmetic / psychological
What are the DDx of acute scrotal pain? (5)
What age group does each usually present in?
Testicular torsion (adolescent 12-18) Hyatid torsion (pre-adolescent 8-12) Epididymal cyst torsion/ epididymitis (middle aged men) Epididymo-orchitis (<35 - STI/UTI) Idiopathic scrotal oedema (<10)
What 2 anatomical features are often present in testicular torsion?
Bell-clapper testis (not anchored properly)
Usually L sided (higher)
List the indications for circumcision? (3)
List the complications? (4)
Pathological phimosis (Lichen sclerosis - unretractable foreskin)
Recurrent UTIs
Recurrent balanoposthitis
Bleeding
Infection
Glans damage
Psychological trauma
How may labial adhesions present? (3)
How treated?
Appears absent vagina (minor adhered)
Perineal soreness
Urinary irritation
Topical oestrogen for 1-2wks
What are some RFs of cleft lip/palate? (2)
Some associated conditions/problems with it? (2)
RFs: chromosomal disorders (polygenic), maternal anticonvulsants
Feeding difficulties
Secretory/acute otitis media
How would a diaphragmatic hernia present? (3)
How Dx
What associated problems
Newborn resp distress
Displaced apex beat (to R)
Displaced heart sounds (to R)
CXR/AXR
Pulm hypoplasia
How may trachea-oesophageal fistula ± atresia present after birth? (4)
How is it managed?
Persistent salivation / drooling
Cough/choke when feed
Aspirations of milk/saliva/gastric acid (fistula)
Cyanotic episodes
Continuous suction + surgery
What is trachea-oesophageal fistula ± atresia assoc w.?
Polyhydramnios
VACTERL
What is the difference b/wn exomphalos + gastroschisis?
How are they both managed? (3)
Exomphalos = abdo contents portruding thru umbilical ring WITHIN peritoneal sac. Often csome abns
Gastroschisis = no covering sac - abdo wall defect adjacent to umbilicus. No assoc congen abns
NG tube + freq aspirations
IV dextrose + colloid
Surgical closure
What is exomphalos also assoc w.? (3)
Csome abnormalities (Trisomy, Turner, Kleinfelter) Bladder + cloacal exostrophy Pentalogy of Cantrell (exomph, ant diaph hernia, cleft sternum, ectopic cord, cardiac defect)
What are the different types of congenital neck cysts in children? (6)
Thyroglossal (midline) Branchial (front/side) Dermoid/teratoid Lymphatic malformation Ectopic thymus Cystic vascular abn
How may a Wilm’s tumour present? (4)
Large abdo mass in well child
Abdo pain
Anorexia
Haematuria
How may a Neuroblastoma present? (7)
Abdo mass crossing midline Spinal cord compression Bone pain Wt loss Malaise Pallor Bruising
What is the incidence of Hirschprungs?
List some RFs/associated conditions (6)
1 in 5000
Boys FH Down's Multiple endocrine neoplasia Malrotation Gastric diverticulum
Describe the pathophysiology behind Hirschprungs
Due to absence of ganglion cells from myenteric + submucosal plexuses in colon
→ Contracted segment from rectum to colon (varies) (75% rectosigmoid)
How does Hirschprung’s disease present in neonates? (3)
What seen O/E (PRE)
Failure to pass meconium in 1st 24hrs
Neonatal intestinal obstrn: Abdo distension Bilious vom (seen more in obstrn above ampulla of vater)
O/E: narrow segment + withdrawn finger → gush
If Hirschprungs is missed in the neonate, how may it present in infants / older children?
Chronic constipation resistant to Tx
Early satiety + abdo discomfort → poor nutrition / wt gain
How is Hirschprung’s Dx / managed?
Dx - suction rectal biopsy (shows absent ganglion cells)
To estimate aganglionic segment
→ anorectal manometry / barium enema
Surgical Tx: initial colostomy
→ anastomose normal innv bowel to anus
What are some complications of Hirschprungs? (3)
Hirschprung’s enterocolitis in 1st wks of life (C.Diff)
Sepsis
Transmural intestinal necrosis / Perforation
What are the features of Hirschprungs enterocolitis (a complication)? (4)
How it is managed?
Fever
Abdo pain
Vomiting
Bloody/foul diarrhoea
→ Urgent broad spec IV Abx + fluids
